| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,475 |
2,411 |
$94K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
985 |
528 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
2,971 |
2,881 |
$76K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
329 |
231 |
$34K |
| D0274 |
Bitewings - four radiographic images |
972 |
952 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,863 |
1,813 |
$30K |
| D1120 |
Prophylaxis - child |
650 |
637 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,115 |
1,053 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
120 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
419 |
308 |
$5K |
| D0330 |
Panoramic radiographic image |
37 |
36 |
$2K |
| D0272 |
Bitewings - two radiographic images |
85 |
85 |
$2K |
| D2330 |
|
17 |
12 |
$1K |
| D9110 |
|
13 |
13 |
$505.11 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$407.28 |